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C H A P T E R 1 Cell Injury, Cell Death, and Adaptations

cells that have lost their ability to regulate intracellular calcium. After initiation in either location, propagation of crystal formation occurs. This is dependent on the concentration of Ca2+ and PO4, the presence of mineral inhibitors, and the degree of collagenization, which enhances the rate of crystal growth. Deposition of glycogen: in macrophages of patients with defects in lysosomal enzymes that break down glycogen (glycogen storage diseases) Deposition of pigments: typically indigestible pigments, such as carbon, lipofuscin (breakdown product of lipid peroxidation), or iron (usually due to overload, as in hemosiderosis) Pathologic calcifications Dystrophic calcification: deposition of calcium at sites of cell injury and necrosis Metastatic calcification: deposition of calcium in normal tissues, caused by hypercalcemia (usually a consequence of parathyroid hormone excess)

Metastatic Calcification
Metastatic calcification can occur in normal tissues whenever there is hypercalcemia. The major causes of hypercalcemia are (1) increased secretion of parathyroid hormone, due to either primary parathyroid tumors or production of parathyroid hormonerelated protein by other malignant tumors; (2) destruction of bone due to the effects of accelerated turnover (e.g., Paget disease), immobilization, or tumors (increased bone catabolism associated with multiple myeloma, leukemia, or diffuse skeletal metastases); (3) vitamin Drelated disorders including vitamin D intoxication and sarcoidosis (in which macrophages activate a vitamin D precursor); and (4) renal failure, in which phosphate retention leads to secondary hyperparathyroidism.

CELLULAR AGING
Individuals age because their cells age. Although public attention on the aging process has traditionally focused on its cosmetic manifestations, aging has important health consequences, because age is one of the strongest independent risk factors for many chronic diseases, such as cancer, Alzheimer disease, and ischemic heart disease. Perhaps one of the most striking discoveries about cellular aging is that it is not simply a consequence of cells running out of steam, but in fact is regulated by a limited number of genes and signaling pathways that are evolutionarily conserved from yeast to mammals. Cellular aging is the result of a progressive decline in the life span and functional capacity of cells. Several mechanisms are thought to be responsible for cellular aging (Fig. 129): DNA damage. A variety of metabolic insults that accumulate over time may result in damage to nuclear and mitochondrial DNA. Although most DNA damage is repaired by DNA repair enzymes, some persists and accumulates as cells age. Some aging syndromes are associated with defects in DNA repair mechanisms, and the life span of experimental animals in some models can be increased if responses to DNA damage are enhanced or proteins that stabilize DNA are introduced. A role of free radicals in DNA damage leading to aging has been postulated but remains controversial. Decreased cellular replication. All normal cells have a limited capacity for replication, and after a fixed number of divisions cells become arrested in a terminally nondividing state, known as replicative senescence. Aging is associated with progressive replicative senescence of cells. Cells from children have the capacity to undergo more rounds of replication than do cells from older people. In contrast, cells from patients with Werner syndrome, a rare disease characterized by premature aging, have a markedly reduced in vitro life span. In human cells, the mechanism of replicative senescence involves progressive shortening of telomeres, which ultimately results in cell cycle arrest. Telomeres are short repeated sequences of DNA present at the ends of linear chromosomes that are important for ensuring the complete replication of chromosome ends and for protecting the ends from fusion and degradation. When somatic cells replicate, a small section of the telomere is not duplicated,

MORPHOLOGY
Regardless of the site, calcium salts are seen on gross examination as fine white granules or clumps, often felt as gritty deposits. Dystrophic calcification is common in areas of caseous necrosis in tuberculosis. Sometimes a tuberculous lymph node is essentially converted to radiopaque stone. On histologic examination, calcification appears as intracellular and/or extracellular basophilic deposits. Over time, heterotopic bone may be formed in the focus of calcification. Metastatic calcification can occur widely throughout the body but principally affects the interstitial tissues of the vasculature, kidneys, lungs, and gastric mucosa. The calcium deposits morphologically resemble those described in dystrophic calcification. Although they generally do not cause clinical dysfunction, extensive calcifications in the lungs may be evident on radiographs and may produce respiratory deficits, and massive deposits in the kidney (nephrocalcinosis) can lead to renal damage.

SUMMARY Abnormal Intracellular Depositions and Calcifications

Abnormal deposits of materials in cells and tissues are the result of excessive intake or defective transport or catabolism. Depositions of lipids Fatty change: accumulation of free triglycerides in cells, resulting from excessive intake or defective transport (often because of defects in synthesis of transport proteins); manifestation of reversible cell injury Cholesterol deposition: result of defective catabolism and excessive intake; in macrophages and smooth muscle cells of vessel walls in atherosclerosis Deposition of proteins: reabsorbed proteins in kidney tubules; immunoglobulins in plasma cells

Cellular Aging
Environmental and metabolic insults ROS? DNA damage
Defective DNA repair

27

Telomere shortening

Abnormal protein homeostasis

Environmental stress Insulin/IGF signaling

Cellular replication

Proteins, damaged proteins

TOR Altered sirtuins Altered transcription

MUTATIONS

CELL LOSS

DECREASED CELL FUNCTIONS

CELLULAR AGING

DNA repair COUNTERACTS AGING Protein homeostasis

Figure 129 Mechanisms that cause and counteract cellular aging. DNA damage, replicative senescence, and decreased and misfolded proteins are among the best described mechanisms of cellular aging. Some environmental stresses, such as calorie restriction, counteract aging by activating various signaling pathways and transcription factors. IGF, insulin-like growth factor; TOR, target of rapamycin.

and telomeres become progressively shortened. As the telomeres become shorter, the ends of chromosomes cannot be protected and are seen as broken DNA, which signals cell cycle arrest. Telomere length is maintained by nucleotide addition mediated by an enzyme called telomerase. Telomerase is a specialized RNA-protein complex that uses its own RNA as a template for adding nucleotides to the ends of chromosomes. Telomerase activity is expressed in germ cells and is present at low levels in stem cells, but it is absent in most somatic tissues (Fig. 130). Therefore, as most somatic cells age their telomeres become shorter and they exit the cell cycle, resulting in an inability to generate new cells to replace damaged ones. Conversely, in immortalized cancer cells, telomerase is usually reactivated and

Germ cells

Stem c

ells

So
Telomere length

at

ic

ce

lls

Cancer cells

Growth arrest Cell divisions

Figure 130 The role of telomeres and telomerase in replicative senescence of cells. Telomere length is plotted against the number of cell divisions. In most normal somatic cells there is no telomerase activity, and telomeres progressively shorten with increasing cell divisions until growth arrest, or senescence, occurs. Germ cells and stem cells both contain active telomerase, but only the germ cells have sufficient levels of the enzyme to stabilize telomere length completely. In cancer cells, telomerase is often reactivated.
(Data from Macmillan Publishers Ltd, from Holt SE, etal: Refining the telomer-telomerase hypothesis of aging and cancer. Nat Biotechnol 14:836, 1996.)

telomere length is stabilized, allowing the cells to proliferate indefinitely. This is discussed more fully in Chapter 5. Telomere shortening may also decrease the regenerative capacity of stem cells, further contri b uting to cellular aging. Despite such alluring observations, however, the relationship of telomerase activity and telomere length to aging has yet to be fully established. Defective protein homeostasis. Over time, cells are unable to maintain normal protein homeostasis, because of increased turnover and decreased synthesis caused by reduced translation of proteins and defective activity of chaperones (which promote normal protein folding), proteasomes (which destroy misfolded proteins) and repair enzymes. Abnormal protein homeostasis can have many effects on cell survival, replication, and functions. In addition, it may lead to accumulation of misfolded proteins, which can trigger pathways of apoptosis. There has been great interest in defining signaling pathways that counteract the aging process, not only because of their obvious therapeutic potential (the search for the elixir of youth) but also because elucidating these pathways might tell us about the mechanisms that cause aging. It is now thought that certain environmental stresses, such as calorie restriction, alter signaling pathways that influence aging (Fig. 129). Among the biochemical alterations that have been described as playing a role in counteracting the aging process are reduced signaling by insulin-like growth factor receptors, reduced activation of kinases (notably the target of rapamycin, [TOR], and the AKT kinase), and altered transcriptional activity. Ultimately these changes lead to improved DNA repair and protein homeostasis and enhanced immunity, all of which inhibit aging. Environmental stresses may also activate proteins of the Sirtuin family, such as Sir2, which function as protein deacetylases. These proteins may deacetylate and thereby activate DNA repair enzymes, thus stabilizing the DNA; in the absence of these proteins, DNA is more prone to damage. Although the role of sirtuins has received a great deal of attention recently, their importance in the aging process is not yet established.

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C H A P T E R 1 Cell Injury, Cell Death, and Adaptations

SUMMARY Cellular Aging

Results from combination of accumulating cellular damage (e.g., by free radicals), reduced capacity to divide (replicative senescence), and reduced ability to repair damaged DNA Accumulation of DNA damage: defective DNA repair mechanisms; conversely DNA repair may be activated by calorie restriction, which is known to prolong aging in model organisms Replicative senescence: reduced capacity of cells to divide secondary to progressive shortening of chromosomal ends (telomeres) Other factors: progressive accumulation of metabolic damage; possible roles of growth factors that promote aging in simple model organisms

It should be apparent that the various forms of cellular derangements and adaptations described in this chapter cover a wide spectrum, ranging from adaptations in cell size, growth, and function, to the reversible and irreversible forms of acute cell injury, to the regulated type of cell death represented by apoptosis. Reference is made to these many different alterations throughout this book, because all instances of organ injury and ultimately all cases of clinical disease arise from derangements in cell structure and function. BIBLIOGRAPHY
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Dong Z, Saikumar P, Weinberg JM, Venkatachalam MA: Calcium in cell injury and death. Annu Rev Pathol 1:405, 2006. [A review of the links between calcium and cell injury.] Elliott MR, Ravichandran KS: Clearance of apoptotic cells: implications in health and disease. J Cell Biol 189:1059, 2010. [An excellent review of the mechanisms by which apoptotic cells are cleared, and how abnormalities in these clearance pathways may result in disease.] Frey N, Olson EN: Cardiac hypertrophy: the good, the bad, and the ugly. Annu Rev Physiol 65:45, 2003. [Excellent discussion of the mechanisms of muscle hypertrophy, using the heart as the paradigm.] Galluzzi L, Aaronson SA, Abrams J, et al: Guidelines for the use and interpretation of assays for monitoring cell death in higher eukaryotes. Cell Death Differ 16:1093, 2009. [A practical summary of the morphologic and other techniques for detecting and quantifying dead cells.] Haigis MC, Yankner BA: The aging stress response. Mol Cell 40:333, 2010. [A review of the role of cellular stresses in controlling the aging process.] Hotchkiss RS, Strasser A, McDunn JE, Swanson PE: Cell death. N Engl J Med 361:1570, 2009. [Excellent review of the major pathways of cell death (necrosis, apoptosis, and autophagy-associated death), and their clinical implications and therapeutic targeting.] Kenyon CJ: The genetics of ageing. Nature 464:504, 2010. [An excellent review of the genes that influence aging, based on human genetic syndromes and studies with mutant model organisms.] Kroemer G, Marino G, Levine B: Autophagy and the integrated stress response. Mol Cell 40:280, 2010. [An excellent discussion of the biology, biochemical pathways, and physiologic roles of autophagy.] Kundu M, Thompson CB: Autophagy: basic principles and relevance to disease. Annu Rev Pathol 3:427, 2008. [A discussion of the biology of autophagy and its potential contribution to a variety of disease states.] Lin JH, Walter P, Yen TSB: Endoplasmic reticulum stress in disease pathogenesis. Annu Rev Pathol 3:399, 2008. [A review of the biology and disease relevance of the unfolded protein response and ER stress induced by unfolded proteins.] Lombard DB, Chua KF, Mostoslavsky R, et al: DNA repair, genome stability, and aging. Cell 120:497, 2005. [The role of DNA damage in cellular aging.] McKinnell IW, Rudnicki MA: Molecular mechanisms of muscle atrophy. Cell 119:907, 2004. [Discussion of the mechanisms of cellular atrophy.] Newmeyer DD, Ferguson-Miller S: Mitochondria: releasing power for life and unleashing the machineries of death. Cell 112:481, 2003. [Excellent review of the many functions of mitochondria, with an emphasis on their role in cell death.] Sahin E, DePinho RA: Linking functional decline of telomeres, mitochondria and stem cells during ageing. Nature 464:520, 2010. [An excellent review of stem cell abnormalities that contribute to aging.] Tosh D, Slack JM: How cells change their phenotype. Nat Rev Mol Cell Biol 3:187, 2002. [Review of metaplasia and the roles of stem cells and genetic reprogramming.] Valko M, Leibfritz D, Moncol J, et al: Free radicals and antioxidants in normal physiological functions and human disease. Int J Biochem Cell Biol 39:44, 2007. [An interesting discussion of the biochemistry of reactive oxygen and nitrogen-derived free radicals, their roles in cell injury, and their physiologic functions as signaling molecules.]